The generation of medical progress notes entered into a patient's file is required for good patient medical care and more recently for payment for rendered medical care from medical insurance companies, Medicare or any other agency. Over the years, the S.O.A.P. format has been developed to achieve continuity and repeatability. S.O.A.P. is an acronym for the four steps used in medical record documentation for a doctor-patient encounter.
S.O.A.P. stands for
Subjective PA1 Objective PA1 Assessment and PA1 Plan.
Currently the individual components of the S.O.A.P. format are handwritten or typed by the physician, dictated, or entered by means of bar coded notes or a voice recognition system. The medical record often lacks continuity and consistency. The time spent in the preparation of the medical documentation detracts from quality time available with the patient. For example, handwriting or dictation of the progress note is obviously the most time consuming of the above-enumerated methods. The bar-coded method requires the doctor to locate the desired sentence or phrase on a wall chart or bar code book having hundreds of words and phrases to choose from. The doctor must then choose the appropriate bar code using a bar code reader to enter the selected word or phrase into a word processor. Current word recognition systems require extremely slow and clearly enunciated speech that can be more time consuming and frustrating for the physician. Like hand written notes, the methods using voice recognition may also result in inconsistencies in describing the same observation assessment or plan for two different patients having the same symptoms.
Computer implementation of various health care procedures and bookkeeping are known in the healthcare industry. For example, Ertel in U.S. Pat. No. 5,307,262 is directed to a method and system to review and control clinical data quality in the reporting of hospital claim data. In particular, as stated in the summary of the Ertel patent, the system utilizes the effeciency of batch operations to analyze claim data or entire groups of patients for the purpose of identifying and correcting both case specific and systematic problems in data quality in the most efficient way possible. Although the system taught by Ertel requires the entry of diagnostic and procedure codes into the system, the codes used by Ertel relate to medical billing and are only used in combination with Medicare's "Diagnosis Related Group" program that assigns a diagnosis-related group and to assign several secondary attributes to the patient data sets along with the actual clinical data being entered. The Ertel system is unrelated to a method of generating office progress notes, of the type entered into a private patient file for the purpose of recording the ongoing events of the doctor-patient relationship in the medical office setting. In the medical office, billing is a separate issue from documentation of the patient's progress.